Accurately completing assessments and charting patient care should be more of a priority for skilled nursing facilities moving forward.

Not only because operators are facing more MDS coordinator shortages and are outsourcing the process as a result, but also reducing hospital stays could be one way SNFs capitalize on value-based care.

At least that’s the case with the SNF value-based purchasing program (VBP).

The question for operators is whether the juice is worth the squeeze.

The program is designed to award SNFs with incentive payments based on the quality of care they provide to Medicare beneficiaries, according to the Centers for Medicare & Medicaid Services. If a facility fails to submit the required quality data then it could be subject to a two percentage point reduction to the annual payment update.

“Keep in mind, 2% when you talk about it to staff, they don’t think that is a lot,” Susan LaGrange, chief nursing officer at Pathway Health, explained during a presentation at the LeadingAge Illinois conference last month. “That 2% is a lot and it adds up and adds dollars that you can use for staffing.” 

Is 2% a big enough draw?

Not everyone is convinced the incentive amounts to enough to get nursing homes involved, however.

The Medicare Payment Advisory Commission (MedPAC) recommended eliminating the program last year due, in part, because the relatively small size of incentive payments may not be enough to motivate providers to improve.

ATI Advisory Managing Director Fred Bentley similarly expressed concern over whether 2% is really enough to get the industry’s attention.

“It’s not earth shattering,” he told Skilled Nursing News. “That’s a totally different story when you’re talking about 5%.”

While Bentley has not heard any indication that CMS plans to increase the percentage at this time, policy makers and industry gurus have discussed the possibility and he anticipates a push to put more “teeth into” the program. 

Still, LaGrange thinks now is the time to prioritize proper coding and additional data recording through education and training — especially with the White House throwing its weight behind the SNF VBP program in recent months.

She said that “every single dollar” is important for nursing homes right now, a message that needs to be widely understood by staff moving forward.

Longevity Health Plan Chief Growth Officer Marc Hudak thinks operators need to be looking ahead when it comes to the program and shifting to additional value-based care opportunities moving forward.

“On one hand 2% doesn’t sound like a whole lot but when you understand the cost pressures that operators have been facing, I do think every bit matters,” he told SNN.

The “broader theme” is that as CMS and the White House continue to articulate their intent to move reimbursement toward more outcome and value-based measures, the importance and relevance of the program will only continue to grow, Hudak added.

The White House directed CMS to propose new payment changes based on staffing adequacy, resident experience and staff retention as part of its push to strengthen the program.

Just because it’s 2% today doesn’t mean it’s going to be 2% tomorrow, he added.

“So 2% today could be 10% some point down the line,” Hudak said. “CMS has said they want everyone in a value-based model by 2030 so I think this is very relevant and although it’s small today this is where the industry is heading in a hurry.” 

Getting agency staff on board

At a time when 71% of operators have hired temporary agency staff in recent months due to staffing shortages, getting every staff member on board and motivated to earn incentive payments back for the facility is not always easy.

Bentley said that “smart SNFs” are doing what they can to minimize agency use though he admitted relying on temporary staff can be “disruptive.”

“We’ve heard of instances where it’s this revolving door of staff and they [aren’t always] truly committed,” he saidadded.

While agency staff can make things “trickier,” according to Bentley, some operators are structuring contracts in such a way that hold the staffers accountable for performance on hospital readmissions the same way that they would hold their own staff accountable.

The program primarily evaluates a nursing home’s performance based on a 30-day hospital readmission measure – scored on both improvement and achievement – and the expectation is that the program will soon expand with other measures under consideration like discharge patterns.

Hudak added that one of the challenges with hiring a lot of temporary or agency staff is that they come in and they’re not trained on the protocol and best practices of the operator.

“If someone wakes up with a fever or a urinary tract infection, [an agency staffer] may send them right to the hospital versus just simply calling the on-call doctor who’s got a plan in place,” he said. “It’s an absolute challenge.”

Giving the staff the tools they need to succeed

The best way to ensure mistakes aren’t repeated as far as coding and quality reporting are concerned is to do a needs assessment to figure out what a facility’s staff does well and what it does not, according to LaGrange.

“It’s so important to have a good process to identify changes and really manage the quality of care to prevent those unnecessary readmissions,” she said. “If staff understands that it provides facilities with more dollars to be able to take care of the residents.”

LaGrange added that it’s not just the temporary staffers and new staff members that can have a hard time completing assessments and documenting changes in a patient’s chart.

She’s seen instances where a change of condition was completed and the assessment is not documented on the chart — not out of negligence but misunderstanding.

“Take a look at your system for changes of condition and the assessment skills of your nurses,” LaGrange said. “We have some really good quality nurses and they’ve provided good care for your residents, but times have changed.”

A missing or inaccurate assessment data may not be a sign the nurse doesn’t want to do it, but rather, they may not feel comfortable because they haven’t done those types of assessments since nursing school.

“It’s really taking a step back and taking a look at what you need to do because if we can take our nurses that we have today and show them, teach them and make them comfortable, you’re going to see much more compliance with those assessments and with that documentation process,” she added.